Basic Information
| Provider Information | |||||||||
| NPI: | 1609830595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FONDREN ORTHOPEDIC GROUP L.L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7401 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137992300 | ||||||||
| FaxNumber: | 7137943395 | ||||||||
| Practice Location | |||||||||
| Address1: | 7401 SOUTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770304509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137992300 | ||||||||
| FaxNumber: | 7137943380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| AuthorizedOfficialLastName: | YATES | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7137992300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 530699 | 01 | TX | BLUE CROSS & BLUE SHIELD ORTHOTICS | OTHER | 00H7N | 01 | TX | BLUE CROSS & BLUE SHIELD | OTHER | 00H7N | 01 | TX | MEDICARE | OTHER | 121422301 | 05 | TX | MEDICAID |